Simultaneous Oral Bullous Pemphigoid and Paraneoplastic Pemphigus Following Photoimmunotherapy

Head and neck cancers pose a significant challenge to clinicians to treat the disease while limiting the amount of morbidity to the patient. Given this need, new trials and medications have been explored to provide tissue sparing therapies. One of these methods being trialed at our institution is photoimmunotherapy with the PD1 inhibitor pembrolizumab. A patient with multiple recurrences of squamous cell carcinoma of the oral cavity underwent trial with photoimmunotherapy, but developed severe lip ulceration and swelling that required the patient to discontinue the trial. Biopsy and antibody testing revealed elevated levels of BP180 and BP230 indicating bullous pemphigoid. In addition, elevated Envoplakin was noted confirming a simultaneous paraneoplastic pemphigus diagnosis. Given the growing number of case reports showing an association of paraneoplastic pemphigus and bullous pemphigoid with pembrolizumab and other PD1 inhibitors, further investigation should be undertaken to better understand the incidence of these diseases with photoimmunotherapy.